Comparative results of autologous skin cell suspension combined with a contact layer dressing versus autologous skin cell suspension and a poly-lactic acid dressing in larger total body surface burns.

INTRODUCTION: Contact layer dressing (CLD) is standard after autologous skin cell suspension (ASCS); however, the authors wondered whether a poly-lactic acid dressing (PLAD) results in superior outcomes and cost savings. MATERIAL AND METHODS: Retrospective cohort study including greater than 10% total body surface area (TBSA) burns treated with ASCS and either PLAD or CLD. Primary outcomes were infection and length of stay (LOS). RESULTS: 71 patients (76% male, 24% pediatric, mean age 37 years) were included. Twenty-eight patients (39%) received CLD and 43 (61%) received PLAD. Wound infections were decreased in PLAD (7 vs 32%, p = 0.009). When controlling for area grafted (cm2) and TBSA, logistic regression revealed odds of post-operative infection was 8.1 times higher in CLD (p = 0.015). PLAD required antibiotics for fewer days (mean 0.47 vs 4.39, p = 0.0074) and shorter LOS (mean 17 vs 29 days, p < 0.001). Mean adjusted charges per %TBSA was $18,459 in PLAD vs. $25,397 in CLD (p = 0.0621). CONCLUSION: In the first analysis of its kind, this study showed polylactic acid dressing combined with autologous skin cell suspension led to a decrease in postoperative infections, length of hospital stay, and total patient charges.

Refining the referral criteria of persons who have been burned to palliative care: A modified Delphi approach.

A paucity of evidence is available to guide integration of specialist palliative care into burn care. This study's purpose was to develop consensus on referral criteria using a modified Delphi process. Content experts were defined as burn or palliative care providers in locations where the teams have collaborative history; published at least one manuscript or presented nationally on burn and palliative care collaboration; or nomination as having equivalent expertise. N = 202 eligible persons were identified; n = 43 participated in Iteration 1 and Iteration 3 retained 79%. Iteration 1 invited participants to rank published referral criteria on a 9-point Likert-style scale. Consensus was defined as an interquartile range ≤ 2. Consensus items with median scores ≤ 3 were dropped from further consideration. Consensus items with median scores ≥ 7 were considered to be important and excluded in Iteration 2. Iteration 2 which presented non-consensus items with their associated median (interquartile range) and the participant's own ranking from Iteration 1. Iteration 3 presented three models; participants ranked in order of preference and suggested revisions. Consensus was achieved on a final set of criteria for specialist palliative care for persons who sustain burn injuries. Future research should prospectively evaluate the criteria against meaningful outcomes.

Integrating Palliative Care into Burn Care: A Retrospective Application of Criteria for Appropriate Referral.

Burn injuries often require complex interdisciplinary care. Despite potential benefits, consultation with specialist palliative care typically occurs in 2% of burn admissions, due largely to lack of availability and misconceptions concerning palliative care. Criteria to guide consultation with specialist palliative care have been developed at this institution. The purpose of this study was to quantify the sensitivity and specificity of these criteria, and then optimize them. Retrospective examination of 388 admissions over 15 months at this adult and pediatric Burn Center were conducted. Chi-square or Fisher's exact test for categorical variables and Wilcoxon Rank Sum test for continuous variables were used to test for between-group differences in demographic and clinical characteristics. Logistic regression model was built to determine modified Baux cut-off score using Youden index (J) value. Criteria were sensitive (0.96) and specific (0.90), though with a low positive predictive value (0.43). Persons with lengths of stay greater than one week, advanced directives, Allow Natural Death orders, and/or deterioration events were significantly more likely to have had palliative care consulted. There were significant between-group differences (with/without palliative care consultation) based on burn surface area, modified Baux score, and mortality risk. Potential criteria revisions are proposed. Prospective adherence to revised criteria could provide useful guidance to providers and benefit to patients and families.

Palliative Care and Burn Care: Empirically Derived Referral Criteria.

Burns frequently require complex interdisciplinary care. Specialist palliative care (PC) minimizes suffering, aids in decision making, and provides family support in addition to end-of-life care. Specialist PC is a limited resource, best conserved by identifying persons most likely to benefit from a PC referral. Little guidance is available for clinicians on whether and when to refer to PC. This study's purpose was to identify referral criteria using a mixed-methods approach. Data were examined for between-group differences using Fisher's exact, chi-square, or Wilcoxon Rank Sum tests. Qualitative thematic analysis was used to analyze PC provider notes to describe interventions provided. These data formed initial referral criteria, which were reviewed by an expert panel. Significant between-group differences included dying in the burn center; whether multiple patients were transported to the burn center from one event; and ventilator days. Four themes emerged from qualitative analysis. These included managing physical aspects of care; clarifying goals of care; managing end-of-life care; and managing patient/family psychosocial distress. Expert panel input clarified referral criteria language and supplemented the proposed criteria. We present empirically derived referral criteria to guide burn providers in referring persons for specialist PC. Subsequent testing is required to determine their efficacy in improving patient/family outcomes.

High-Volume Hemodiafiltration with Step-Down Approach versus Standard-of-Care Continuous Renal Replacement Therapy Approach in Critically Ill Burn Patients.

INTRODUCTION: Acute kidney injury (AKI) is a common complication of severe burn injuries and contributes to morbidity and mortality. It is exacerbated in burn patients by elevated serum creatinine and pro-inflammatory cytokines, leading to immune dysregulation. Chronic renal replacement therapy is standard of care and removes cytokines to return the body to homeostasis. Continuous veno-venous hemodiafiltration (CVVHDF) is a high-filtration method to enhance cytokine clearance; we analyze a step-down approach for improved outcomes in burn patients. METHODS: This study reviewed 15 burn patients at Akron Children's Hospital stratified into 2 groups: high-flow CVVHDF with step-down approach versus standard CVVHDF. A normocarbia bicarbonate-based dialysate solution and citrate anticoagulation was applied, and blood flow rate was maintained greater than 200 mL/min. RESULTS: Fifteen burn patients at Akron Children's Hospital were separated into groups managed with high-flow CVVHDF (n = 9) and standard-flow CVVHDF (n = 6). All 15 developed AKI symptoms and diuretic-resistant fluid overload, with 4/15 displaying fluid overload greater than 40%. The most common indication for hemofiltration was acute tubular necrosis (11/15). Average time on CVVHDF was 20.2 days and length of admission was 58.6 days. Vasodepressor dependency index was significantly reduced in the high-flow group at 48 h, but no significant difference in mortality was identified. No significant difference was identified in adverse reactions, notably electrolyte imbalances. CONCLUSION: The literature on the efficacy of high-flow CVVHDF is limited. This study suggests improved mortality rates and length of stay with high flow compared to the literature. Further studies with multicenter involvement are necessary.

Correction of Pterygium Colli in Turner Syndrome: A Clinical Report and Review of the Surgical Management.

The aim of surgery for pterygium colli (PC) is to correct the contour deformity, redistribute or remove the horizontal excess of skin, address the abnormal posterior hairline, avoid excessive scarring, and prevent recurrence. The purpose of this study is to review the available methods to correct the deformity and highlight a recent patient performed by the senior author. A modified bilateral Z-plasty technique was used for correcting PC on a 5-year-old African American girl diagnosed with Turner syndrome. The patient had an uneventful postoperative period and satisfactory functional and esthetic results were demonstrated at 1 year follow-up. The approach used was a variation of a lateral approach. Using the proposed approach, excision and complete release of the scar contracture and less tension, which reduces the rate of recurrence compared with the posterior approaches, is achieved. Moreover, the current technique avoids myotomies, which can put the spinal accessory nerve at risk, and lateral Z-plasties which the authors find unnecessary. Instead, the advancement of each anterior flap is limited in the posterosuperior direction so that the flaps do not meet in the posterior midline. This limits the pull and tension on the entire closure. Although several techniques have been described over the years, the search for the ideal type of surgical treatment is still ongoing.

The use of skin substitutes in hand burns.

Several skin substitutes are available that can be used in the management of hand burns; some are intended as temporary covers to expedite healing of shallow burns and others are intended to be used in the surgical management of deep burns. An understanding of skin biology and the relative benefits of each product are needed to determine the optimal role of these products in hand burn management.